Country Gardens Health And Rehabilitation Center
COUNTRY GARDENS HEALTH AND REHABILITATION CENTER in SWANSEA, MA — inspection on July 1, 2024.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #78's Brief Interview for Mental Status (BIMS) assessment, dated 4/4/24, indicated Resident #78 was cognitively intact as evidenced by a score of 15 out of 15.
During an interview with observation on 6/24/24 at 9:10 A.M., Resident #78 said he/she brought the CPAP from home and that he/she manages the CPAP themselves.
The surveyor observed a CPAP machine on Resident #78's nightstand with the CPAP mask in the top drawer, a one-gallon distilled water jug was noted next to his/her nightstand.
Review of Resident #78's medical record failed to indicate Resident #78 had an order for their CPAP.
During an interview on 6/25/24 at 8:50 A.M., Resident #78 said he/she would wear their CPAP sometimes. Resident #78 said the nurses would fill the water reservoir with distilled water and turn the machine on for him/her.
225185
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 225185 B.
Wing 07/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Gardens Health and Rehabilitation Center 2045 Grand Army Highway Swansea, MA 02777
During an interview on 6/26/24 at 4:27 P.M., the Administrator said the doctors and nurse practitioners would fax their notes to the fax machine and the two boxes of medical records were waiting to be filed.
The Administrator said the door to the copy room should be locked to protect resident information because it is accessible to anyone walking by.
On 6/26/24 at 4:51 P.M., the surveyor observed the door to the copy room of the main hallway with the door open and unattended with two boxes labeled medical records visible from the hallway and physician notes which included medical diagnoses and resident face sheets on the fax machine.
Upon further investigation, the boxes labeled medical records contained but were not limited to hospital discharge summaries and resident diagnoses.
During an interview on 6/26/24 at 4:55 P.M., the Chief Nursing Officer (CNO) said the door to copy room should have been closed and locked because the room contains residents' personal medical information but it was not.
34145
225185
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 225185 B.
Wing 07/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Gardens Health and Rehabilitation Center 2045 Grand Army Highway Swansea, MA 02777
Review of the facility's policy titled High Risk, dated 3/4/24, indicated but was not limited to the following:
- Policy: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications.
This policy addresses the facility's collaborative, systemic approach to managing anticoagulant therapy for efficacy and safety.
Policy Explanation and Compliance Guidelines:
- The resident's plan of care shall alert staff to monitor for adverse consequences.
Risks associated with anticoagulants include:
a.
Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine and stool)
b.
Fall in hematocrit or blood pressure
c.
Thromboembolism (a dangerous condition that occurs when a blood clot breaks free)
A. Resident #231 was admitted to the facility in June 2024 with diagnoses including hypertension and alcohol abuse.
Review of Resident #231's Minimum Data Set (MDS) assessment, dated 6/8/24, indicated Resident #231 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15.
Further review of the MDS indicated that Resident #231 received anticoagulant medication.
Review of Resident #231's current Physician's Orders indicated but was not limited to:
- Enoxaparin Sodium (anticoagulant) 40 milligrams (mg)/0.4 milliliter (ml) Inject subcutaneously (under the skin) one time a day (6/5/24)
Review of Resident #231's June 2024 Medication Administration Record (MAR) indicated he/she received Enoxaparin Sodium as ordered.
225185
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 225185 B.
Wing 07/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Gardens Health and Rehabilitation Center 2045 Grand Army Highway Swansea, MA 02777